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Issue 1176
IAC Express: Weekly immunization news and information

Issue 1176: April 2, 2015

Ask the Experts: CDC Experts Answer Your Questions


Four questions and answers (Q&As) in this edition of IAC Express first appeared in the March 2015 issue of Needle Tips. The additional Q&As are included as a special reward for our loyal IAC Express readers.

IAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH, and nurse educator Donna L. Weaver, RN, MN, both from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Pneumococcal Vaccines

Combination Vaccines Scheduling Vaccines Administering Vaccines Vaccine Recommendations

Pneumococcal Vaccines
Q: We have a healthy 78-year-old female patient who received PCV13 (Prevnar13, Pfizer), then received PPSV23 (Pneumovax 23, Merck) approximately 5 weeks later. She had not received PPSV23 previously. Is the PPSV23 dose valid, or does it need to be repeated?

A: What to do when doses of PCV13 and PPSV23 are given without the recommended minimum interval between them isn’t spelled out in the new ACIP pneumococcal recommendations. The CDC subject matter experts have provided the following guidance: in such a case, the dose given second does not need to be repeated. This is an exception to the usual procedure for a minimum interval violation (as described in ACIP’s General Recommendations on Immunization). For your reference, the recommended interval between the dose of PCV13 and PPSV23 is 6 to 12 months and the recommended minimum interval between doses is 8 weeks.

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Q: Why is it recommended to give PCV13 before PPSV23 to adults age 65 years and older? Wouldn’t PPSV23 protect them against ten additional strains of the pneumococcal virus?

A: PCV13 is recommended to be given first because of the immune response to the vaccine when given in this sequence. An evaluation of immune response after a second pneumococcal vaccination administered 1 year after an initial dose showed that subjects who received PPSV23 as the initial dose had lower antibody responses after subsequent administration of PCV13 than those who had received PCV13 as the initial dose followed by a dose of PPSV23.

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Q: Rather than giving PCV13 first and waiting 8 weeks to give PPSV23 as recommended for an immunocompromised child (2 years or older) or adult patient, we inadvertently gave both vaccines at the same visit. We are looking for guidance.

A: Although PCV13 and PPSV23 should not be administered at the same visit, CDC does not recommend repeating either vaccine dose should this occur.

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Combination  Vaccines
Q: A dose of Kinrix (DTaP-IPV; GlaxoSmithKline) was inadvertently given to a 4-month-old in our practice who needed DTaP and IPV. Can this dose be considered valid?

A: Kinrix is only licensed for use as the fifth dose of the DTaP vaccine series and the fourth dose of the IPV series in children age 4–6 years. CDC has provided this guidance for when Kinrix is given off-label:
  • Kinrix given to a child younger than 4 years as DTaP and IPV doses 1, 2, or 3: Count as valid if all minimum intervals met.
  • Kinrix given to a child younger than 4 years as DTaP and IPV doses #4 and/or #5: Count as valid for DTaP #4; not valid for DTaP #5 or IPV #4, both of which must be administered at age 4–6 years.
However, you should check with your state immunization program to see what they will accept. Checking with your state is particularly important for validating a last dose of IPV vaccine administered before the fourth birthday. Their guidance may vary depending on the date of administration or your upcoming travel plans. Contact information can be found here: www.immunize.org/coordinators.

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Scheduling Vaccines
Q: Two live virus vaccines can be given on the same day. How do you define “day”?

A: The “same day” generally means at the same visit. This interval has not been precisely defined and probably will never be since it would be extremely difficult to study in order to develop an evidence- based recommendation. Immunization programs (and their computer systems) likely define this differently. It seems reasonable that if two vaccines were given on the same date then they would both be valid.

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Administering Vaccines
Q: I recently had a patient ask if we could administer her baby's rotavirus vaccine in her pumped breast milk. Would this be acceptable?

A: No. Although ACIP does not specifically address this, it introduces a number of possible problems: possible loss of vaccine effectiveness when mixed with another liquid, possible contamination, possible temperature excursion, and potential loss of volume (e.g., if baby didn't drink the entire volume).

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Q: One of our young patients made it impossible to administer the second part of the live attenuated influenza vaccine (LAIV; FluMist) dose. What should we do?

A: A half dose of LAIV (or any other vaccine) is a non-standard dose and should not be counted. If you weren't able to give the second half of the vaccine at that same appointment, you will have to provide another full dose of influenza vaccine at another time. If you want to try using a different route, you can give inactivated influenza vaccine any time after this partial dose. If you want to give LAIV again, you should wait four weeks, as it is a live vaccine.

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Vaccine Recommendations
Q: Does ACIP have any special recommendations regarding immunization in unimmunized children with celiac disease?

A: Celiac disease is neither an indication nor contraindication for any specific vaccines. Children with celiac disease should be vaccinated as indicated by their age.

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Q: What vaccines should I administer to an infant who will be traveling internationally?

A: Infants who will travel outside the United States should be up to date for all routinely recommended vaccines. One dose of MMR is recommended for infants age 6 through 11 months before international travel. This dose does not count toward the two doses needed to complete the childhood schedule. Varicella vaccine is not recommended before age 12 months, even for travelers. An infant younger than age 12 months who is traveling to a hepatitis A endemic area should receive immune globulin (IG), not hepatitis A vaccine (for details, see ACIP recommendations: Update: Prevention of Hepatitis A After Exposure to Hepatitis A Virus and in International Travelers). For other vaccine recommendations for travelers, consult CDC Health Information for International Travel: 2014 (“Yellow Book”).

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How to submit a question to Ask the Experts

IAC works with CDC to compile new Ask the Experts Q&As for our publications based on commonly asked questions. We also consider the need to provide information about new vaccines and recommendations. Most of the questions are thus a composite of several inquiries.

You can email your question about vaccines or immunization to IAC at admin@immunize.org.

As we receive hundreds of emails each month, we cannot promise that we will print your specific question in our Ask the Experts feature. However, you will get an answer.

You can also email CDC's immunization experts directly at nipinfo@cdc.gov. There is no charge for this service.

If you have a question about IAC materials or services, email admininfo@immunize.org.

Please forward these Ask the Experts Q&As to your colleagues and ask them to subscribe to IAC Express.

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About IAC Express 
We encourage you to reprint any of these Q&As in your own newsletters. Please credit the Immunization Action Coalition and the Centers for Disease Control and Prevention. Please refer to IAC's preferred citation style.
If you have trouble receiving or displaying IAC Express messages, visit our online help section.
IAC Express is supported in part by Grant No. U38IP000589 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC. IAC Express is also supported by educational grants from the following companies: bioCSL Inc.; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
IAC Express Disclaimer
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